Laparotomy,TAH,BSO,Lysis of adhesions,examination under anesthesia

pamsridharan

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Exam under anesthesia 57410
Laparoscopy with lysis of adhesions with BSO 58661-22-51
TAH 58150



PREOPERATIVE DIAGNOSIS:
1. Fibroid uterus. icd 218.9
2. Pelvic pain, chronic. icd 625.9

POSTOPERATIVE DIAGNOSIS:
1. Fibroid uterus.
2. Pelvic pain, chronic.

OPERATION(S) PERFORMED:
1. Laparotomy.
2. Total abdominal hysterectomy.
3. Bilateral salpingo-oophorectomy.
4. Lysis of adhesions.
5. Examination under anesthesia.


IV FLUIDS: 2600.

URINE OUTPUT: 350.

ESTIMATED BLOOD LOSS: 150..

ANTIBIOTICS: 1 g of Ancef prior to incision.

OPERATIVE FINDINGS: Exam under anesthesia revealed normal external
genitalia, a 6- to 8-week size uterus palpated in the midline.
Intraoperatively a globular, asymmetric, midposition uterus visualized.
Extensive adhesions noted of the omentum attached to the anterior
abdominal wall; the adhesions were thickly adhesed to approximately an
area of 10 x 10 cm of omentum in the supraumbilical area going up into
the midline upper quadrants bilaterally underneath the peritoneal
cavity.

COMPLICATIONS: None.

DRAINS: JP drain placed.

BACKGROUND: The patient is a 59-year-old, G1, P1 with a history of
symptomatic uterine fibroids status post Lupron, endometrial ablation
and uterine artery embolization. The patient reports chronic pelvic and
abdominal pain and therefore desires definitive surgical management for
symptomatic uterine fibroids.

OPERATIVE PROCEDURE: Prior to being taken to the operating
room, the patient was consented for the above-mentioned procedures.
She was taken to the operating room and
successfully induced under general anesthesia. In the dorsal supine
position she was prepped and draped in the normal sterile fashion. A bimanual
exam was performed,
and the above findings were noted. A time-out was called to confirm correct
patient and correct procedure.

A Pfannenstiel skin incision was made in the skin with a scalpel and
then carried down to the underlying fascia with the Bovie. Hemostasis
was maintained using Bovie electrocautery. The fascia was nicked in the
midline and extended laterally using a Bovie. The superior aspect of
the fascial incision was grasped with 2 Kocher clamps and elevated, and
the underlying layer of the rectus muscle was dissected off with a
Bovie. Attention was then directed to the inferior aspect of the
fascial incision which was elevated with 2 Kocher clamps, and the
underlying layer of rectus muscle was dissected off with a Bovie. The
rectus muscle was divided at the midline, and the peritoneum was
identified. The peritoneum was grasped with hemostats and entered with
curved Metzenbaum sharply. An approximately 1 cm defect in the
peritoneum was created with Metzenbaum scissors under direct
visualization and extended inferiorly with Bovie cautery under direct
visualization. Of note, thick adhesions were palpated and then
visualized prior to extension of the peritoneal incision. The
peritoneum of the upper abdomen was carefully extended under direct
vision with the Bovie.

A Collins self-retaining retractor was inserted into the abdominal cavity and
opened with a pelvic exposure.
Several moist lap sponges were tagged with hemostats and placed into the
abdominal cavity for packing of the bowel. Attention was turned to the
left side where 2 peans were placed side-to-side over the round
ligament. The round ligament was cauterized. The lateral aspect of the
round ligament was then suture ligated with 0 Vicryl. The suture was
tagged with a hemostat and left long. The round ligament incision was
then extended into the anterior leaf of the broad ligament to the point
of the intersection of the bladder and the uterus. Care was taken to
avoid dissection of the ureter.

Attention was then turned to the posterior leaf of the broad ligament
where a small defect in the leaf was created under direct visualization
with the Bovie. A finger was inserted into the defect, and 2 peans were
placed to double clamp the infundibulopelvic ligament lateral to the
ovaries. The ligaments were cut using a scalpel and suture ligated using
0 Vicryl. Attention was then turned to the right side where
the process was repeated under direct visualization with excellent
hemostasis noted.

The bladder was separated from the lower uterus and the upper cervix by
blunt dissection with a sponge stick. The bladder was mobilized away
from the cervix and upper anterior vaginal wall. The uterine corpus was
retracted to expose the uterine vessel. Using curved Heaney, the left
uterine vessels were bilaterally clamped at the level of the internal
cervical os at right angles to the lower uterine segment. The vessels
were cut with a scalpel and freed from the uterus by extending the
incision to the tip of the clamp. 0 Vicryl sutures were placed at the
angles of the incisions, the tips of the clamps taking care to ensure
that all vessels were secured by ligatures. The cardinal ligaments of
the uterus exposed were then identified, clamped, cut and double ligated
with 0 Vicryl suture. Attention was then turned to the right side where
the process was repeated under direct visualization with excellent
hemostasis noted.

Given the difficulty in manipulating and accessing
the cervix due to the globular shape of the uterus, decision was made at
this time to cauterize the cervix at the level of the internal os for
removal of the uterus; the cauterization was performed under direct
visualization, and the uterus was detached as it would be in a
supracervical hysterectomy. The remaining stump of the cervix was then
clamped bilaterally with a curved Heaney parallel to the plane of the cervix;
the
lateral cervix was incised with scalpels along the edge of the Heaney
clamp and ligated with 0 Vicryl suture for excellent hemostasis. This
process was carried down to the base of the ectocervix. Then the
remaining portion of the cervix was then excised using Jorgenson
scissors and sent to Pathology.

The vaginal cuff was then reapproximated using a running stitch from the left
apex down to the
right apex with a 2nd imbricating stitch to reapproximate the peritoneal
lining over the underlying vaginal cuff. The pelvis was re-inspected,
and all pedicles and vaginal cuff were inspected for hemostasis.

Attention was turned to the thick omental adhesions underlying the
abdominal peritoneum. Using sharp dissection with curved Metzenbaum
scissors, an attempt was made to remove the adhesions from the anterior
abdominal wall, given the patient had complaints of pelvic pain as well
as abdominal pain. Given the extent of the adhesions, lysis was aborted
due to severity.

The peritoneum was closed with 2-0 suture in a running
fashion. Muscle was reapproximated with 20-0 suture in running fashion.
The fascia was closed with 0 Vicryl suture in running fashion. The
subcutaneous tissue was reapproximated with 3-0 plain in the a running
fashion. The skin was reapproximated with 4 Monocryl in a subcuticular
stitch. All sponge, lap and instrument counts were correct x2
 
Last edited:

bonzaibex

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58150 is the only billable code I can pick out of the op note. A laparoscopy was not done, and the BSO is included in the 58150. The 57410 is going to be bundled into the TAH. If your physician feels s/he spent an extraordinary amount of time on the 58150, you can bill out a 58150-22. The diagnosis coding is correct.

Becky, CPC
 

sknapp56

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I agree totally with Becky. The only billable code you have is the 58150 and you can use the 22 modifier for the adhesions.

Sue, CPC, COBGC
 
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